Cultural Competency Nursing CE Course

1.5 ANCC Contact Hours AACN Category B

Disclosure Form

This module addresses cultural influences on health and illness, describes the position of providing culturally competent nursing care to diverse populations, and identifies current evidence-based practice guidelines for culturally competent care.

Upon completion of the activity, participants will be able to:

  1. describe cultural influences on health and illness
  2. describe the theory of providing culturally competent care to patients
  3. identify current evidence-based practice guidelines for culturally competent care

Terms to Know

Cultural competency means the provider understands and addresses the entire cultural context of each client within the domain of care. Culturally competent care means providing medical care in a way that considers each patient's values, beliefs, and practices (Georgetown University Health Policy Institute, n.d.). The National Institutes of Health (NIH) defines the delivery of culturally competent care as respectful and receptive to the health ideas, practices, cultural and linguistic needs of diverse patients (Nair & Adetayo, 2019). Similarly, the following terms may also be used to describe care that is delivered within the context of a patient's culture: 

  • Culturally sensitive care means the provider is aware and knowledgeable of different cultures and their prevalence in the local community (Potter et al., 2017).
  • Culturally appropriate care means the provider applies their knowledge of a client's culture to their care delivery (Potter et al., 2017).
  • Culturally congruent care is customized to the individual's culture, health-illness context, needs, values, and beliefs (Leininger, 1999). 
  • Transcultural nursing means to provide health care to patients based on their culture, values, health-illness context, and beliefs (Leininger, 1999).

Culture is "the integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations" (Merriam-Webster, 2020). Potter and colleagues (2017) highlight norms, values, and traditions passed down from generation to generation in their definition of culture. 

A disability is any condition of the mind or body that creates difficulties in performing activities and/or interacting with the world (The Centers for Disease Control and Prevention [CDC], 2020).

Faith is a strong belief in something or an unseen higher power (Potter et al., 2017).

A health disparity is any form of inequality in health outcomes between populations. It is influenced by sex, sexual identity, ethnicity, age, disability, socioeconomic status, and geographic location (US Department of Health and Human Services' [HHS] Office of Disease Prevention and Health Promotion [ODPHP], 2020). 

The term LGBTQIA stands for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minorities (National LGBTQIA+ Health and Education Center, 2020).

Religion is a system of beliefs that are practiced to express spirituality (Potter et al., 2017).

Spirituality refers to connectedness within oneself, as well as with others, the environment, and an unseen higher power (Potter et al., 2017).

Introduction

Culture comprises a group of people who share beliefs, faith systems, values, ways of thinking, and acting. Culture provides a framework in which illness is defined, as people tend to react differently to disease based on their cultural perspective. Patients vary widely in their cultural and spiritual backgrounds and belief systems. Culture includes multiple attributes such as communication style, language, customs, norms, traditions, religion, art, music, dress, health beliefs, and health practices. Since culture influences health beliefs and health practices (refer to Table 1), healthcare providers (HCPs) must examine and address their preconceptions before they can provide optimal culture and spiritual care to their clients (Potter et al., 2017). 

Additionally, ethnicity, race, gender, sexual orientation, and immigration status are all essential considerations in the expanding view of culture. Nurse theorist Madeleine Leininger (1999) explained transcultural nursing as a comparative study of cultures to understand their similarities and differences. In essence, the goal of transcultural nursing is to provide culturally congruent care that is meaningful and compatible with the patient's values. For example, rather than advising all patients to take medications simultaneously during a day, a nurse can provide culturally congruent care by learning about each patient's lifestyle and customizing their recommendations to fit this lifestyle. Through culturally competent care, an HCP can focus their efforts to offer personalized care (Leininger, 1999). In other words, culturally competent care is a process by which HCPs provide individualized care, which is crucial to reduce healthcare disparities (Albougami et al., 2016). Table 1 identifies cultural groups, specific healthcare beliefs and responses to illness, and related implications for HCPs.

The relationships between an HCP's and patient's knowledge, attitudes, skills, and behaviors are ongoing and multidimensional. An HCP's behaviors are affected by their knowledge of a particular culture and its impact on their beliefs, their attitudes towards certain age or racial groups (including unconscious biases and stereotypes), and their skills in intercultural communication (including their ability to function with a medical interpreter). HCPs are indoctrinated into the culture of Western medicine early, with its characteristic language, customs, behaviors, and even attire, and may lose their sense of human connection with their patients, focusing more on the measurement and standardization of laboratory and diagnostic tests, pharmacological treatments, and surgical procedures. These coalesce into exhibited behaviors by the HCP, such as communication style, respect, sensitivity, shared decision-making, and self-management support. Similarly, a patient's behaviors are affected by their knowledge (i.e., English language and health literacy); attitudes towards Western medicine, HCPs, and protective truthfulness; and their skills regarding communication with HCPs and navigation of the US healthcare system. Protective truthfulness is the concept espoused in many cultures that the patient deserves to be protected from the harsh reality of the clinical information by a close group of trusted family, friends, or surrogates who act collectively to filter information for the patient and/or collectively make treatment decisions. Acculturation also affects patient behavior, which is the "degree to which persons from a particular racial and ethnic background have incorporated the cultural attributes of the mainstream culture" (Periyakoil, 2019, p. S425). Cultures also define acceptable behaviors to communicate distress independently, and these may vary widely. All of this combines to create patient behaviors such as expression of values/preferences, informed decision-making, treatment adherence, self-advocacy, and self-management. The final complicating factor is that the HCP's and the patient's behaviors also interact and affect each other on a continuous and ongoing basis (Periyakoil, 2019).

Cultural Competency and the Importance of Providing Culturally Competent Care

The HHS Healthy People 2020 initiative defines a health disparity as a specific difference in obtaining health care based on social, economic, and/or environmental disadvantage. In the US, many people face challenges with receiving quality and stable health care due to one or more of the following factors: 

  • racial or ethnic group 
  • faith 
  • income level 
  • age
  • disability (cognitive, sensory, or physical) 
  • sexual orientation 
  • gender identity 
  • other characteristics that are linked to discrimination (ODPHP, 2020)

There is a strong link between social determinants and health care disparity in the literature. Social attributes such as income/wealth, education, access to health care, family and household structure, social support, occupation, neighborhood conditions, and social institutions are examples of social determinants of health (Potter et al., 2017). A lack of access to health care is one of the crucial social determinants contributing to healthcare disparities. Research also suggests less care is accessible by lower socioeconomic groups compared to higher income groups (CDC, 2013). 

More than a decade ago, reports by the Institute of Medicine (IOM, 2001, 2010) identified high-quality health care as equitable, accessible, timely, quality, efficient, safe, effective, and patient-centered. Although US health care has improved in certain areas, it still lacks equity, as evidenced by literature data (ODPHP, 2020). This may be due to inadequate resources, including but not limited to access to language services, as well as poor patient-provider communication and a lack of culturally competent care (Potter et al., 2017). 

Certain syndromes or illnesses can primarily affect a specific culture or group of people due to family history, inherited genetic mutations, or shared environmental factors. The non-Hispanic White (NHW) population has a higher rate of most types of cancers than Asian Americans, whereas Asian Americans have a higher incidence of liver cancer as compared to Hispanic individuals, NHWs, and non-Hispanic Black (NHB) patients. Although life expectancy and US population health overall has improved during the past 50 years, the health of members of disadvantaged groups has not improved to the same degree. The infant mortality rate for NHBs is more than double the rate experienced by NHWs. The mortality rate due to stroke and coronary artery disease before age 75 is 50% higher among NHBs than among NHWs. Diabetes prevalence is higher among NHBs, Hispanics, multiracial individuals, persons without a college degree, and those with a lower household income (CDC, 2013; Quiñones et al., 2019). 

Furthermore, approximately 61 million US adults are affected by a disability, which translates to 26% of the US population. Disabled individuals face many health disparities, such as higher rates of obesity, smoking, and inactivity; fewer preventive screenings; and higher rates of death from breast and lung cancers (CDC, 2020). Research also suggests that some subgroups of LGBTQIA+ people have more chronic conditions with a higher prevalence and an earlier onset of disabilities than individuals who do not identify as LGBTQIA+ (National LGBTQIA+ Health and Education Center, 2020). In the US, the LGBTQIA+ population has increased to 4.5%, highlighting the need for additional cultural competence to reduce healthcare disparities for this community in particular (Gallup, 2018). 

NHB adults (over age 18) have higher rates of hypertension (41%) than their NHW counterparts (28.3%). Adult mortality rates related to heart disease and stroke, common chronic diseases targeted in the HealthyPeople2020 initiative, are also higher among NHB adults as compared to NHW adults, as shown in Figure 1 (ODPHP, n.d.). Additionally, the population within these groups is expected to rise over the next four decades, as shown in Figure 2. By 2050, one in five Americans will be over the age of 65, and racial and ethnic minorities will comprise about 35% of the older adult population (Georgetown University Health Policy Institute, n.d.). 

In 2018, "26.7% of Hispanic, 15.2% of NHB, 9.0% of NHW, and 8.1% of non-Hispanic Asian adults aged 18–64 lacked health insurance" (see Figure 3; CDC, 2018). A higher proportion of some minority groups do not have health insurance compared to NHWs. This lack of coverage leads to reduced access to needed care. Research demonstrates that uninsured individuals aged 0 to 64 are less likely to have a regular primary care provider than those with insurance (Agency for Healthcare Research and Quality [AHRQ], 2014). Uninsured adults without a regular primary care provider receive fewer preventative visits than insured adults. In a 2018 survey, as many as 52% of uninsured adults under age 65 report no regular source from which to obtain medical care, and 21% went without needed care due to cost (as compared to just 4% of privately and 7% of publicly insured adults surveyed). Due to the Affordable Care Act (ACA), the number of uninsured Americans decreased steadily from 2010, when it was 46.5 million, through 2016, when it was 27 million. Unfortunately, reductions in the ACA since 2016 have reversed that trend and increased the number of uninsured Americans back up to 27.9 million in 2018 (Tolbert et al., 2019).

Research indicates that ethnic minority groups continue to exhibit decreased rates of health care utilization for preventative and diagnostic services even after reaching the age of Medicare eligibility (Quiñones et al., 2019). Other factors also contribute to healthcare disparities, outside of the lack of insurance coverage. Obstacles to literacy also influence access to and increase the cost of health care. Individuals with lower literacy skills utilize health services more frequently, which creates between 3 and 6% additional healthcare costs (Georgetown University Health Policy Institute, n.d.). Inequities in health care lead not only to poor health outcomes, but they also contribute to the distrust of HCPs and the healthcare system in general as well as poor patient adherence to the treatment plan. Healthcare disparities are not only burdensome to individuals but also affect community-wide economics through indirect impacts such as lost efficiency at work, sick absences, and financial stress on families (Periyakoil, 2019). By focusing on care that is culturally competent, providers can help to reduce healthcare disparities. Culturally competent care can enhance rapport with patients, reduce healthcare disparities and healthcare costs, as well as improve patient health outcomes and satisfaction (Jongen et al., 2018; Periyakoil, 2019). 

Evidence-Based Practice Guidelines for Culturally Competent Care

In modern-day society, many individuals choose to express their personal values regarding sexual orientation, politics, culture, and religion. According to the National Center for Cultural Competence (NCCC) framework, culturally competent organizations should value diversity, conduct ongoing cultural self-assessments, manage the dynamics of difference, institutionalize cultural knowledge, and adapt to variety (Georgetown University NCCC, 2009). To address these unique and individualized patient needs, HCPs and organizations first should perform a self-assessment of their organizational culture. Each member of the healthcare team must become aware of their values and beliefs to refrain from imposing them on others. Periyakoil (2019) observes that self-assessment can help clinicians identify personal barriers to enhance understanding of various cultures. Specific barriers to culturally competent care include the following:

  • addressing stereotypes based on ethnicity
  • cultural differences
  • racial bias
  • personal bias
  • language barriers
  • lack of culturally competent care training
  • lack of inclusiveness training (Periyakoil, 2019)

A common health system-related barrier is a lack of culturally tailored services, including access to medical interpreters. Healthcare organizations and providers need to work cooperatively to understand and develop the appropriate knowledge, attitude, and skills to deliver the best care to all patients. The importance and value of HCP training regarding cultural competence cannot be overstated. HCPs must listen, understand, and then communicate with their patients using respectful intercultural communication, and this is a skill that can be modeled, practiced, and therefore improved upon. This training should be immersive and skill oriented (Periyakoil, 2019). Many healthcare organizations offer guidance on providing culturally competent care. One of the pioneers of this effort in the US is the HHS Office of Minority Health (OMH, 2018). The OMH developed the culturally and linguistically appropriate standards (CLAS) in 2000 and updated them in 2013. The intention of the enhanced CLAS standards is to assist healthcare organizations by establishing a blueprint for providing equitable and high-quality health care and eliminating disparities. CLAS standards have thus far been successful in helping to create a culturally competent environment for healthcare organizations, providers, and patients (OMH, 2018). 

Culturally competent care promotes health and healing. Below are two examples of delivering culturally competent care through the application of CLAS standards:

  • If a patient values spirituality, find a way to integrate spiritual and medical practices for healing.
  • If a family elder must participate in all medical decisions in a patient's culture, be confident that the patient gave permission and then involve the elder in the care of that patient (OMH, 2018).

Similarly, Larry Purnell, a transcultural nurse theorist, provides a model for cultural competence that highlights 12 cultural domains, which are listed below.  

  • overview/heritage
  • communication
  • family roles and organization
  • workforce issues
  • biocultural ecology
  • high-risk behaviors
  • nutrition
  • pregnancy and childbearing
  • death rituals
  • spirituality
  • healthcare practices
  • healthcare practitioners

Purnell's model includes the foundation for understanding various cultural attributes and highlights patients' characteristics, such as their experiences and beliefs about health care and illness (National Association of School Nurses, 2013). Purnell considered these 12 domains to be crucial in helping providers determine the traits and characteristics of different ethnic groups and deliver culturally competent care. As shown in Figure 5, the model consists of concentric circles: the inner circle represents the individual, the middle circle represents their family, and the outermost circle represents the community/global society (Purnell, 2002). It provides a comprehensive view of culture and helps HCPs ask critical questions to better understand patients' perspectives, culture, and health or illness beliefs.

As summarized by these models, HCPs should complete a comprehensive cultural assessment to understand each patient's worldviews and willingness to receive care. Research also suggests that HCPs ask patients open-ended questions using Kleinman's explanatory model to elicit the patient's perception of illness and how it should be treated. These open-ended questions include:

  • What do you call your problem?
  • What do you think caused the problem? 
  • When did it start?
  • Why do you think it started?
  • How does illness affect you?
  • What are your concerns? 
  • How should your sickness be treated (Potter et al., 2017)?

Healthcare providers may use the 4 Cs of culture by Slavin, Galanti, and Kuo to perform the cultural assessment. The 4 Cs of culture are call, cope, concerns, and cause. The HCP should ask open-ended questions based on the 4Cs to perform a cultural assessment. Examples include:

  • What do you call the problem you are having now?
  • How do you cope with the problem?
  • What are your concerns regarding the problem?
  • What do you think caused the problem (Understanding Cultural Diversity in Healthcare, 2019)? 

Lastly, HCPs should use practical communication skills to connect with patients in a culturally congruent way. A few authors have developed communication mnemonics; one of the most frequently used is to LEARN, which stands for listen, explain, acknowledge, recommend, and negotiate. The HCP should listen with empathy to the patient's explanation of the presenting problem. Next, the HCP should explain their perception of the problem to the patient, acknowledge and discuss cultural differences and similarities with the patient, and then recommend treatment while involving the patient. Lastly, the provider negotiates an agreement that incorporates pertinent aspects of the patient's culture into their care (Potter et al., 2017). The use of medical interpreters (MIs) is a skill that should be covered/reviewed with HCPs as a component of cultural competency training. This includes how to assess whether an MI is needed and discuss this need with the patient to ensure they consent to the use of an MI. When using an MI, HCPs should be trained to brief the MI prior to the appointment regarding the most crucial aspects before the patient arrives to ensure efficient transfer of information and to request that the MI utilize conduit-style interpretation, which is literal interpretation delivered in the first person without interpretation, summarization, or omission. HCPs should speak in short sentences and avoid extensive use of medical jargon except when necessary. HCPs should sit across from the patient at eye level and speak directly to the patient, allowing a clear and unobstructed view of the patient and the HCP by the MI. When doing a physical examination, a curtain should be used to protect the patient's privacy while still allowing the MI the ability to hear and continue to interpret during the examination. A short debrief with the MI following the examination should occur, thanking them for their assistance, and the medical record should include the MI's name and any other prudent agency contact information. Alternative training may include how best to delegate responsibilities to other HCPs when time and resources are scarce and the use of community health workers (CHWs). CHWs are community members with some health promotion/services training, although they are not licensed healthcare professionals. CHWs may be able to meet patients at their homes or within their communities and often share cultural, ethnicity, language, socioeconomic status, or other values and life experiences in common with the patient. CHWs may be volunteers or paid employees of a healthcare system or community organization. They may be able to play a crucial role in scheduling appointments, arranging transportation, providing interpretation services, tailoring patient education, and facilitating treatment plan adherence. The Stanford In-Reach for Successful Aging and End-of-Life (iSAGE) minifellowship is an example of a training program designed for CHWs. This particular program was able to prove a documented increase in goals of care, patient satisfaction, and reduced health care utilization and cost over time with the use of well-trained CHWs (Periyakoil, 2019).

Future Considerations

The AHRQ (2014) studies cultural competence and proposes the alternative term of diversity competence. A universal approach, CLAS standards, targeted strategies, and inclusiveness are required to provide competent care to all populations, including communities that are often overlooked in research, such as persons with disabilities and the LGBTQIA+ population (AHRQ, 2014). The US Bureau of Labor Statistics has predicted a 13% increase in CHW jobs over the next six years. This is in part due to the Bipartisan Budget Act of 2018 and changes to Medicare Advantage, allowing for payment for CHW services. This includes reimbursement for in-home, non-skilled care for assistance with activities of daily living, grocery/meal delivery, and medical transport (non-emergency). CHWs may provide crucial support to the HCPs as resources are stretched to care for the aging, diverse American population in decades to come (Periyakoil, 2019).

Conclusion

Cultural competence is a fundamental part of health care that can increase patient satisfaction and overall quality of care, but healthcare disparities inflate costs and contribute to poor population health. Culturally competent HCPs and organizations can help eliminate health disparities and improve the quality of care. To achieve cultural competence, HCPs need to perform a comprehensive cultural assessment on patients by using an explanatory model to understand each patient's views on health and illness. Cultural competence is an ongoing, long-term process for HCPs and organizations. 

Case Studies

Case Study #1

Mr. Emil Prado is a 45-year-old overweight Hispanic man who was diagnosed with diabetes two years ago and has been insulin-dependent since last month. Mr. Prado has not received any formal education. The patient worked as a roofer until recently but lost his job after the company downsized. Mr. Prado does not have any other job training. As a result, he has not secured another job. The patient has no health insurance, cannot pay for rent or prescriptions, and recently became homeless. 

This morning, Mr. Prado arrived at the emergency department (ED) with a blood glucose (BG) level of 322 mg/dL and hemoglobin A1C of 11%. Upon reviewing the chart, the RN notices the patient has been non-compliant with care and had several repeated admissions to the ED recently. 

1. Based on the explanatory model, what questions should the nurse ask Mr. Prado during a cultural assessment?

Answer: 

  • What do you call your problem?
  • What do you think caused the problem? 
  • When did it start?
  • Why do you think it started?
  • How does illness affect you?
  • What are your concerns?
  • How should your sickness be treated?

2. Which social determinants of health will the nurse likely discover while conducting a cultural assessment with Mr. Prado?

Answer: Some of the social determinants highlighted in the case are:

  • lack of resources to meet daily needs such as safe housing, food, etc.
  • lack of formal education 
  • gap in employment
  • lack of health insurance
  • lack of resources to pay for prescriptions

3. Based on a cultural assessment, the nurse discovers that Mr. Prado doesn't have insurance or a place to stay. What should the nurse do to provide resources to the patient?

Answer: The nurse should consult with the social worker and case manager of the facility. The social worker may be able to provide information about a community health center that offers a BG management program for Mr. Prado. The nurse should also discuss a realistic way to manage his diabetes, given his challenging circumstances. Additionally, the social worker could offer possible housing and unemployment resources. 

Case Study #2 

Daisy is an RN at a nephrology clinic. Amal arrives 30 minutes late for his appointment. Daisy asks Amal if he encountered any problems that caused him to be late. Amal replies, "No, nothing significant." Daisy is frustrated and reminds Amal that timeliness is expected. Amal is offended by Daisy's lack of respect and leaves the clinic, thinking he is no longer welcomed as a patient. 

How would you advise the RN to handle this situation differently in the future?

Answer: Explain to the RN that in some cultures, time is seen as a valuable, finite resource. Other cultures may have a more flexible concept of time. In the future, instead of acting frustrated, the RN can educate each patient on the importance of being on time for their appointment. 


References


Agency for Healthcare Research and Quality. (2014). Improving cultural competence to reduce health disparities for priority populations. https://effectivehealthcare.ahrq.gov/products/cultural-competence/research-protocol 

Aimee.ball. (2018). Diagram of Purnell model [image]. Wikimedia Commons https://commons.wikimedia.org/wiki/File:Diagram_of_the_Purnell_Model.png 

Albougami, A. S., Pounds, K. G., & Alotaibi, J. S. (2016). Comparison of four cultural competence models in transcultural nursing: A discussion paper. International Archives of Nursing and Healthcare Care, 2(4), 053. https://doi.org/10.23937/2469-5823/1510053

The Centers for Disease Control and Prevention. (2013). CDC health disparities and inequalities report. https://www.cdc.gov/minorityhealth/chdireport.html

The Centers for Disease Control and Prevention. (2018). National health interview survey early release program. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201905.pdf

The Centers for Disease Control and Prevention. (2020). Disability and health promotion. https://www.cdc.gov/ncbddd/disabilityandhealth/index.html 

Gallup. (2018).  In the US, estimate of LGBT population rises to 4.5%. https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx

Georgetown University Health Policy Institute. (n.d.). Cultural competence in health care: Is it important for people with chronic conditions? Retrieved September 27, 2020, from https://hpi.georgetown.edu/cultural/

Georgetown University National Center for Cultural Competence. (2009). Conceptual frameworks/models, guiding values and principles. https://nccc.georgetown.edu/foundations/framework.php

Jongen, C., McCalman, J., & Bainbridge, R. (2018). Health workforce cultural competency interventions: A systematic scoping review. BMC health services research, 18(1), 232. https://doi.org/10.1186/s12913-018-3001-5

Leininger, M. M. (1999). What is transcultural nursing and culturally competent care? Journal of Transcultural Nursing, 10(1), 9. https://doi.org/10.1177/104365969901000105 

Masaqui. (2013). Projection of demographics in USA [image]. Wikimedia Commons https://commons.wikimedia.org/wiki/File:Projection_of_the_Demographics_in_USA.jpg 

Merriam-Webster. (2020). Definition of culture. https://www.merriam-webster.com/dictionary/culture

Nair, L., & Adetayo, O. A. (2019). Cultural competence and ethnic diversity in healthcare. Plastic and Reconstructive Surgery – Global Open, 7(5), e2219. https://doi.org/10.1097/GOX.0000000000002219

National Association of School Nurses. (2013). Purnell model for cultural competence by Larry Purnell. https://www.nasn.org/nasn-resources/practice-topics/cultural-competency/cultural-competency-purnell-model 

National LGBTQIA+ Health and Education Center. (2020). LGBTQIA+ glossary of terms for healthcare teams. https://www.lgbtqiahealtheducation.org/publication/lgbtqia-glossary-of-terms-for-health-care-teams 

Office of Disease Prevention and Health Promotion. (n.d.) Data search. https://www.healthypeople.gov/2020/data-search/Search-the-Data#topic-area=3516;topic-area=3499;

Office of Disease Prevention and Health Promotion. (2020). Disparities. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

Office of Minority Health. (2018). The national CLAS standards. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53  

Periyakoil, V. S. (2019). Building a culturally competent workforce to care for diverse older adults: Scope of the problem and potential solutions. Journal of American Geriatrics Society, 67, S423–S432. https://doi.org/10.1111/jgs.15939

Pew Research Center. (2020). Religious landscape study. https://www.pewforum.org/religious-landscape-study/

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017). Fundamentals of nursing (9th ed.). Elsevier. 

Purnell, L. (2002). The Purnell model for cultural competence. Journal of Transcultural Nursing, 13(3), 193-196. https://doi.org/10.1177/10459602013003006

Quiñones, A. R., Botoseneanu, A., Markwardt, S., Nagel, C. L., Newsom, J. T., Dorr, D. A., & Allore, H. G. (2019). Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults. PloS One, 14(6), e0218462. https://doi.org/10.1371/journal.pone.0218462

Tolbert, J., Orgera, K., Singer, N., & Damico, A. (2019). Key facts about the uninsured population. Keiser Family Foundation. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/

Understanding Cultural Diversity in Healthcare. (2019). The 4Cs. https://www.ggalanti.org/the-4cs-of-culture/